It is hereby
submitted that on the...................................... Day
of............................, 2000, personal injury was caused
to..................................... residing at.................... by
accident arising out of and in the course of employment during on................................................................
The said injury
has resulted in temporary disablement to the said workman whereby it is
estimated that he will be prevented from earning more than of his previous/ any
wage for a period................................ Months. The said workman has
been in receipt of half-monthly payments which have continued from
the................day of........................200- until
the..........................day of.............................. 200-, amounting
total of Rs........... The said workman's monthly wages are estimated at
Rs................. The workman is over the age of 25 years. It is further
submitted that............................ I, the employer of the said workman
has agreed to pay, and the said workman has agreed to accept, the sum of
Rs...................... in full settlement of all and every claim under the
Workmen's Compensation Act, 1923, in respect of all disablement of a temporary
nature arising out of the said accident, whether now or hereafter to become
manifest. It is, therefore, requested that this memorandum be duly recorded.
Dated.......................
Signature of
employer..................................................
Witness.........................................................................
Signature of
workman......................................
Witness.........................................................................
Receipt (to be
filled in when the money has actually been paid)
In accordance with the above agreement, I
have on this............ day of .......... received the sum of
Rs..........
Dated
............200 .
.............................workman
The money has
been paid and this receipt signed in my presence.
.............................witness
*The form may be
varied to suit special cases, e.g., injury by occupational disease agreement
when workman is under legal disability etc.
[CD1]Form of
Agreement between the Employer and Workman Regarding Compensation for Injury
Caused to Workman by Accident
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